Provider Demographics
NPI:1053416321
Name:BOBB, RETHA K (PNP)
Entity type:Individual
Prefix:
First Name:RETHA
Middle Name:K
Last Name:BOBB
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:1068 UNION ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3016
Practice Address - Country:US
Practice Address - Phone:207-947-0147
Practice Address - Fax:207-990-3365
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER020258363L00000X
MEAP081666363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME336370099Medicaid